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Job Description:

Position Summary

The Clinical Pharmacy Specialist will perform duties in the following areas across all lines of business, including Utilization Management, Formulary Support, Appeals and Grievances, and Audit and Reporting Support to support the pharmacy team.

This position will perform duties reviewing coverage for medications under the pharmacy and medical benefits for all lines of business necessary. The Clinical Pharmacy Specialist utilizes established company guidelines to review requests from physicians, medical groups, pharmacies, and members for the utilization of prescription drugs and pharmacy benefits. The specialist will conduct, research, and resolve any inquiries, problems, or issues in a timely manner.

The Clinical Pharmacy Specialist is responsible for supervising and directing the support services needed for pharmacy services across all lines of business. This team member will continuously look for ways to improve processes and contribute to corporate and department objectives by processing all requests in a prompt, professional and courteous manner.

Responsibilities

Utilization Management: Prior Authorization for Medical and Pharmacy Benefit (Medicare Part B and Part D; Commercial Plans)

• Input, review and decision Medicare Part B requests for J codes, Q codes, and other medical benefits drugs/supplies.
• Track and triage coverage determinations and/or prior authorization requests submitted from providers and determine if a pharmacist review is required.
• Monitor prior authorization system to ensure turnaround times are met and contact providers for additional information to facilitate coverage determination reviews.
• Refer coverage determination requests for specialty drugs to a delegated vendor or client for processing when applicable.
• Communicate prior authorization criteria, pharmacy benefit coverage, and formulary alternatives to physicians, physician`s office staff, medical management staff and/or pharmacists.
• Notify physicians, providers, and members of coverage determination request decisions.
• Oversight and preparation of correspondence, proposals, reports, spreadsheets, and forms.
• Assist in maintaining policies & procedures, including editing, proofreading.
• Provide project management assistance to pharmacist and team as needed.
• Support member and provider calls regarding authorization, benefit inquiries, and resolution of pharmacy-related member questions as well as outbound customer service calls to members and delegated partners.
• Coordination and completion of intake/processing for pharmacy and medical authorization and appeal requests. Perform preliminary review for completeness and appropriate documentation. Triage and escalate to the appropriate clinical resource when needed.
• Utilize knowledge of member eligibility and benefit coverage information to respond accurately to authorization requests, which do not require review/consultation by a pharmacist.
• Support the pharmacist or Pharmacy Director with quality and STARS related measures, including outreach to members, providers, and pharmacies.

Formulary Support

• Assist the Director in maintenance of the formulary and processing formulary change requests on a weekly basis.
• Support team in generating, maintaining, and reviewing Formulary Status Grids.
• Assist pharmacist in audits and quality checks on the current formulary status for accuracy and contract compliance.

Appeals and Grievances

• Responsible for intake/entry and investigation/resolution of all prescription-related grievances received by the Plan or PBM
• Identify validity of appeal and send request to correct department as appropriate.
• Other appeal tasks as required.

Audit and Reporting Support

• Assist pharmacist in a range of tasks necessary for pharmacy audit and recovery functions, including:
  • Perform audits and quality checks on active prior authorizations claims.
  • Review paid claims for quantity and/or billing discrepancies.
  • Investigate member complaints and documentation of findings according to Fraud Waste and Abuse (FWA) program.
• Support pharmacist in monitoring delegated PBM functions through generation of reports and the review of reports such as daily rejected claims, in depth monthly review of approved and rejected claims, monthly review of posted/published formulary, monthly review of redeterminations and prescription related grievances, and Coverage Gap Discount discrepancy reports.
• Communicate or fax inquiries to pharmacies related to review findings and updates pharmacy database with incoming phone calls, faxes, and e-mails.
• Responsible for the maintenance of consistent processes and updating of policies and procedures and standard operating procedures as assigned.
• Assist pharmacist with department preparation for internal and external audits (building case files, universes, evidence of compliance and other documentation as needed)
• Medicare Part D Operations, including:
  • Assist with identifying and correcting eligibility and group issues.
  • Process member claims and pharmacy claims.
  • Review and process Medicare Advantage Prescription Drug Event (PDE) data, such as:
    • Identification of errors with member eligibility, Low Income Subsidy Cost Sharing, as well as processing Institutional, ESRD and Hospice prescription drug claims.
    • Monitor and report prescription drug metrics, including but not limited to, review of B versus D drugs, appropriate Copay and Deductible calculation, and corrective actions for informational and rejected PDE claims.

Other Responsibilities

• Serve as a training resource for other team members and identifies and shares best practices.
• Provide administrative support to the Pharmacy Director for Committees chaired by Chief Medical Officer.
• Assist with pharmacy matters across all lines of business.
• Develop professional relationships with physicians, physician’s office staff, medical management staff and/or pharmacists.
• Demonstrate understanding and accurate interpretation to support compliance with regulatory standards, e.g. Medicare Advantage and HIPAA.
• Prioritize and plan work for completion in a timely manner, coordinating with others as needed, and meeting deadlines set for all phases of work.
• Maintain a high level of professionalism, safeguarding and preserving the confidentiality of all information in accordance with HIPAA regulations.
• Demonstrate the ability to adapt to changes in the workload and responsibilities.
• Perform other activities and functions related to pharmacy or UM as delegated by the pharmacist or Pharmacy Director to evolve with business needs.

Experience

• Problem Solving and Decision Making: Identifies, analyzes, organizes, and solves problems and issues in a timely, effective manner; uses data and input from others to make sound, timely decisions even in the face of uncertainty.
• Integrity: Consistently honors commitments and takes responsibility for actions and words.
• Flexibility: Demonstrates adaptability and openness to alternative solutions and flexibility when interacting with others, understanding their attitudes, needs, interests, and perspectives.
• Inclusiveness: The ability to network and partner with all internal and external stakeholders including broad and diverse representation of private/public and traditional/non-traditional community organizations.
• At least three years of experience in a health plan or PBM performing prior authorization for drugs, particularly Medicare Part B and Part D.
• Attention to details in obtaining complete and accurate information.
• Ability to key data accurately and efficiently.
• Ability to communicate effectively, including written and verbal communication skills.
• Business English and/or technical vocabulary related to health care industry (insurance/medical terminology).
• Basic knowledge of medical terminology and current diagnostic and reimbursement coding (J/Q codes, ICD-10, CMS 1500, etc.).
• Proficiency in Pharmacy computerized systems and software applications, as well as MS Office Product Suite.
• Excellent phone manner and ability to handle multiple phone lines.
• Ability to identify and trouble-shoot problematic issues independently.
• Ability to follow clinical criteria and instructions to approve prior authorization requests.
• Must be able to meet established deadlines.

Education

Minimum A.A. degree

Licensure/Certifications

License/Certification: Active Pharmacy Technician License required.

$30.00 per hour

Assigned Work Hours:

Position Type:

Regular